Readings of state and health neoliberal government

Henrique Sater de Andrade Sergio Resende Carvalho Cathana Freitas de Oliveira About the authors

Abstract

Brazilian Public Health has often analyzed neoliberalism as a phenomenon of emptying the role of the State and a threat to public and universal health. Taking Foucault's governmental thought as a subsidy, we discuss neoliberalism as a profound metamorphosis, not only of the State, but of health production. As a permanent update of liberalism, the neoliberal government changes the boundaries between public and private and produces new forms of normality, risk and subjectivity, progressively subordinate to the truth of the logic of the economy and the market. This economic rationality creates new ideals of health, inspired by management techniques of corporations, and produces new biological, sanitary, psychological truths. Restricted to “successful self-entrepreneurs”, health may become a moral and economic choice in relation to individual behavior and risk, making the State not responsible and creating a type of economic citizenship devoid of solidarity. However, the game around non-corporate health institutions and practices remains open. It is up to us to question the “responsible” and “safe” life forms that were invented for us and to develop other governmentalities that are less excluding and unequal compared to those that we have naturalized and practiced.

Keywords:
Neoliberalism; Government; Public Health

An important generation of workers, researchers and activists from the Brazilian health movement was forged in the struggles for citizenship and rights. The very existence of the Brazilian public health system was directly influenced by multiple democracy experiences, a context in which the theoretical-practical Brazilian Public Health field also emerged (CARVALHO, 2005CARVALHO, S. R. Saúde coletiva e promoção da saúde: sujeito e mudança. São Paulo: Editora Hucitec , 2005.) . The defense of public policies and social rights and the strengthening and expansion of the State is a prominent feature that has historically unified the Brazilian health movement, despite important controversies, debates and internal differences.

Therefore, we can affirm that the history of Brazilian Collective Health - and also of Latin American Social Medicine - was and continues to be underpinned by a negative view of “neoliberalism”, which is seen as a political-economic phenomenon that puts at risk the principles of sanitary reform and the implementation of a public, universal and comprehensive health system.

It is identified and analyzed, in this context, the contradiction between the constitutional principle of “health as a universal right and a State duty” and “neoliberal policies” that, under the 1990s Collor presidency, would have a growing influence on the Brazilian political and economic scenario. SUS (Brazilian Public Health System), which formally became institutionalized as a public policy in Brazil in 1990, will suffer attacks from neoliberal initiatives that pose numerous obstacles to its consolidation.

Neoliberalism is associated, in this hegemonic perspective, to the emptying of the State's role in the provision of public services and to the production of inequalities, commodification of life and financialization of the economy. In the name of the free market and the accumulation of capital, it limits social spending and has as its target image a smaller and more efficient state, free of bureaucracy and subordinated to the private initiative (CARVALHO, 2009CARVALHO, S. R. Reflexões sobre o tema da cidadania e a produção de subjetividade no SUS. In: CARVALHO, S. R.; BARROS, M. E. B. DE; FERIGATO, S. (Eds.). Conexões: saúde coletiva e políticas de subjetividade. Saúde em debate. São Paulo: Editora Hucitec , 2009.).

Different publications (CAMPOS, 1991CAMPOS, G. W. S. A saúde pública e a defesa da vida. São Paulo: Editora Hucitec, 1991.; COHN, 2008COHN, A. A reforma sanitária brasileira: a vitória sobre o modelo neoliberal. Social Medicine, v. 3, n. 2, p. 82-94, 8 jul. 2008.; LAURELL; COHN; CONTRERA, 2009LAURELL, A. C.; COHN, A.; CONTRERA, R. L. Estado e políticas sociais no neoliberalismo. São Paulo: Cortez, 2009.; MERHY; BUENO, 1996MERHY, E.; BUENO, W. S. Os equívocos da NOB 96: uma proposta em sintonia com os projetos neoliberalizantes? Anais da Conferência Nacional de Saúde. Brasília, 1996.; PAIM; TEIXEIRA, 2007PAIM, J. S.; TEIXEIRA, C. F. Configuração institucional e gestão do Sistema Único de Saúde: problemas e desafios. Ciência & Saúde Coletiva, v. 12, n. supl, p. 1819-1829, nov. 2007.; RIZZOTTO, 2012) affirm that neoliberalism rejects the concept of social rights, the obligation of society to guarantee them via the State, and that its reforms in the health sector attack the Sanitary Reform and the Federal Constitution itself, through spending cuts and and privatizations. Although with internal differences and different emphases, these readings see neoliberalism as an obstacle to the organizational and political consolidation of SUS, making it even more vulnerable to dismantling.

We share, in this sense, the position of a good part of the Collective Health scholars according to whom the resistance to the neoliberal offensive on the Sanitary Reform is not only a contemporary issue, but it is becoming more and more urgent and necessary. Daily new attacks on harshly conquered rights and setbacks in different fields translate into a permanent movement that seeks to undermine the historic and democratic conquest of the right to health as a duty of the State enshrined in the text of the Brazilian 1988 Constitution.

Our goal here is to contribute to this movement of resistance and the necessary reinvention of the founding premises of SUS, through a critical theoretical effort that, while recognizing and affirming the importance of essential principles and successful practices, seeks to explore and develop new theoretical offerings to the consolidation of the public and universal system in times of neoliberal, conservative and authoritarian intensification.

In addition to these permanent challenges, we seek to bring some contributions to the debate around neoliberalism, emphasizing it less as a macroeconomic and political system and more as a rationality of government and production of our regimes of truth, power and subjectivity, which has been profoundly changing the way we think and organize the health field. Its principles and values not only transformed the government of the State, but also of health, in addition to working relationships, educational practices, and different aspects of human life.

We will take as a subsidy the “governmental” thinking of Michel Foucault - and contemporary authors who have been dialoguing with him (BARRY; OSBORNE; ROSE, 1996BARRY, A.; OSBORNE, T.; ROSE, N. (Eds.). Foucault and Political Reason: Liberalism, Neo-Liberalism, and Rationalities of Government. Chicago: University of Chicago Press, 1996.; BROWN, 2015BROWN, W. Undoing the Demos: Neoliberalism’s Stealth Revolution. New York: Zone Books, 2015.; DEAN, 2010DEAN, M. Governmentality: power and rule in modern society. 2a ed. London; Thousand Oaks, California: SAGE, 2010.; GORDON, 1991GORDON, C. (Ed.). The {Foucault} effect: studies in governmentality: with two lectures by and an interview with {Michel} {Foucault}.Chicago: University of Chicago Press , 1991.; MILLER; ROSE, 2013MILLER, P.; ROSE, N. S. Governing the present: administering economic, social and personal life. Cambridge Malden: Polity Press, 2013.; OKSALA, 2013OKSALA, J. Feminism and Neoliberal Governmentality. Foucault Studies, p. 32-53, 22 ago. 2013.; ROSE, 1999) , including those linked to the field of Brazilian Public Health (BENEVIDES; PRESTES, 2014BENEVIDES, P. S.; PRESTES, T. K. A. Biopolítica e governamentalidade: uma análise da Política Nacional sobre Drogas. ECOS - Estudos Contemporâneos da Subjetividade, v. 4, n. 2, p. 274-287, 6 dez. 2014.; CAPONI, 2014CAPONI, S. O DSM-V como dispositivo de segurança. Physis: Revista de Saúde Coletiva , v. 24, n. 3, p. 741-763, set. 2014.; CARVALHO, 2015CARVALHO, S. R. Governamentalidade, ‘Sociedade Liberal Avançada’ e Saúde: diálogos com Nikolas Rose (Parte 1). Interface - Comunicação, Saúde, Educação, v. 19, n. 54, p. 647-658, set. 2015.; CARVALHO; ANDRADE; OLIVEIRA, 2019ANDRADE, H. S. DE; CARVALHO, S. R.; OLIVEIRA, C. Governo da subjetividade (e resistências) da clínica na atenção primária. In: CARVALHO, S. R. et al. (Orgs.). Vivências do cuidado na rua: produção de vida em territórios marginais. Rio de Janeiro: Rede Unida, 2019. p. 109-122.; MERHY et al., 2019MERHY, E. E. et al. Rede Básica, campo de forças e micropolítica: implicações para a gestão e cuidado em saúde. Saúde em Debate, v. 43, n. spe6, p. 70-83, 2019.) - to discuss the neoliberal government of health and the State. Above all, we are interested in questioning whether our aspirations for social rights have been obstructed not only by a neoliberal ideology present in the conformation of the State and Brazilian public policies, but also by a complex neoliberal reconfiguration of the forms of health and subjectivity government and our relationships with others and with ourselves.

Governmentality, biopolitics and liberalism

In the course “Security, Territory and Population”, Foucault (2008aFOUCAULT, M. Segurança, território, população. Curso dado no Collège de France (1977-1978). São Paulo: Martins Fontes, 2008a.) analyzes the transformation and reactivation of the legal-legal and disciplinary techniques of power in the contemporary and the development and complexification of new government practices and technologies.

This passage in the philosopher's thought is made possible through the diagram of governmentality, a concept that he did not use when investigating modern clinic, psychiatry, hospital and prisons. The fusion between the words “government” and “mentality” indicates that it is not possible to study the technologies of power without analyzing what ways of thinking and acting intertwine them; the forms of political power from the 18th century onwards were linked to the growth of government devices and a complex field of knowledge about the government itself, its form of exercise and the nature of those on which it should act (MILLER; ROSE, 2013MILLER, P.; ROSE, N. S. Governing the present: administering economic, social and personal life. Cambridge Malden: Polity Press, 2013.).

A varied use of the concept of government is proposed in addition to its strictly political denotation. Foucault starts from a formulation of a little-known text from 1567 - “government is the right disposition of things, arranged so as to lead to a convenient end” (Guillaume de La Perrière) - to affirm that to govern means to take charge of men, of their relationships, of their bonds, in their overlapping with their customs, habits, ways of doing or thinking. This shift towards government produces an important cleavage in the traditional meaning of the exercise of political power. The government is pointed out here as an action with varying levels of systematicity, regulation and self-reflection and that goes beyond a spontaneous, fluid and random exercise of power (ANDRADE; CARVALHO; OLIVEIRA, 2019CARVALHO, S. R.; ANDRADE, H. S. DE; OLIVEIRA, C. F. DE. O governo das condutas e os riscos do risco na saúde. Interface - Comunicação, Saúde, Educação, v. 23, e190208, 2019.) .

It is neither a constituted authority or a sovereign State, but in the exercise of “conducting the conduct” of individuals and groups, a wide and heterogeneous web of management of individual and collective conduct connected to calculation procedures, experiment and evaluation. In addition, “mentality” is seen not as a representation of reality, but of the perpetual fabrication of discursive regimes of knowing where the exercise of power is thinkable, rationalizable and has its practical implementation made possible (LEMKE, 2002LEMKE, T. Foucault, Governmentality, and Critique. Rethinking Marxism, v. 14, n. 3, p. 49-64, set. 2002.).

Governmentality becomes a vector in the work of authors who realized the power of the concept to think about the State and politics, but also other social phenomena not directly related to the state or to the public sphere. Without seeking to unify a general theory of government, these studies seek to investigate the heterogeneity of the governing authorities and the questions around which the problems surrounding the government were formed. In them, the techniques and practices of power would not be a reflection or representation of an idealized political purpose, but effects of the very uses of government tools and “dispositifs” and of the possibilities and limits of their regimes of truth and practice. Analyzing the government here means asking how a particular problem was shaped in a “thinkable and manageable” way, the places where these problems were formed and the authorities responsible for enunciating them, the techniques and devices invented, the modes of authority and engineered subjectivity; not just the purposes of these ambitions and strategies (ROSE, 1999, p. 21-22ROSE, N. Powers of Freedom. Cambridge: Cambridge University Press, 1999.).

This diagram fulfills a number of functions in the analysis of power. In addition, as already said, to offer a vision that breaks with the idea of ​​power as domination or violence; it connects the techniques of the self with practices of vigilance, discipline, domination and improvement; together it thinks about the constitution of subjectivity with the formation of the State and of the historical devices that shaped it (medicine, psychiatry, prison, hospital, factory, etc.).

The cleavage of the government's meaning as “conduct of conduct” implies a link between political power and morality, that is, in thinking about the other's own actions or actions based on a self-regulation linked to certain values, principles and judgments. In this sense, governing always involves an aspiration and relationship to values of a “good”, “virtuous” and “desirable” life. In addition, the government does not always require a governor and a governed: the individual himself is questioning his own conduct and increasingly seeking a greater capacity to conduct it in a way that he deems appropriate, responsible, virtuous, healthy, profitable, morally acceptable, etc.

Thus, these analyses observe not only the exercise of authority and power over citizens, the State, the population, but also the ways in which we govern ourselves. There is an intrinsic connection between government and subjectivity; governmental thinking takes a look at how our desires, choices, needs are shaped, our search for health and normality, our ideals of autonomy and self-esteem and, not least, our ways of experiencing life.

This exercise of power techniques and practices requires not only disciplinary mechanisms over individuals, but also government over the population. It is in the name of the population's health, its longevity, well-being, prosperity, security, happiness, etc. that different forms and practices of government, including those centered on the State, will be structured historically.

In the vertex between government and population, the concept of biopolitics is inserted. We understand biopolitics here generally as a policy related to the administration of life and especially in the context of populations. A way of thinking and problematizing the government's practice in relation to health, life expectancy, birth rate and mortality, racial issues and a broad set of attributes that characterize and constitute the population (DEAN, 2010DEAN, M. Governmentality: power and rule in modern society. 2a ed. London; Thousand Oaks, California: SAGE, 2010.; ESPOSITO, 2008ESPOSITO, R. Bios: Biopolitics and Philosophy. Tradução: Timothy Campbell. 1 ed. Minneapolis: Univ. Minnesota Press, 2008.; GORDON, 1991GORDON, C. (Ed.). The {Foucault} effect: studies in governmentality: with two lectures by and an interview with {Michel} {Foucault}.Chicago: University of Chicago Press , 1991.; RABINOW; ROSE, 2006RABINOW, P.; ROSE, N. Biopower Today. BioSocieties, v. 1, n. 2, p. 195-217, jun. 2006.; SAFATLE, 2015SAFATLE, V. Uma certa latitude: Georges Canguilhem, biopolítica e vida como errância. Scientiae Studia, v. 13, n. 2, p. 335-367, jun. 2015.) .

This life management is linked here to political economy: how families live, under what conditions, how many times a day they clean themselves, how they reproduce, how they get sick, what kind of work they do, to what risks they are exposed to. In short, a set of issues that social medicine, public health, social assistance and other fields of knowledge and power will address and around which they will structure their biopolitical strategies.

Managing life means mapping all this social body and identifying its possible sources of danger, error, abnormality. Risk and normality, thus, assume a central function: more than disciplining, monitoring and punishing those who violate the law and social norms, it is necessary to calculate, in the name of the safety of the population as a whole and the maintenance of stability, the “normal” and “acceptable” possibilities and rates of violation of these standards. The government of the population requires ideals of normality and normalization: what are the appropriate levels for a city's crimes? How many people can go hungry without a rebellion? How many murders? What is the ideal infant mortality rate? How much inequality in a society is acceptable? To sum up, governing is managing risk and calculating how to decrease or increase the chances of a certain event; how to interfere with factors that interfere with that probability; how to predict individual and population phenomena and events.

Therefore, governmentality and biopolitics are transversal axes in this historical analysis of the mutations in the exercise of political power. Biopolitics (and, more broadly, biopower) does not mean for this thinking a conscious strategy of a dominant class or a unique set of interests. Although intrinsic to the history and proliferation of state mechanisms, these biopolitical devices are not created by or because of the State, stricto sensu. Modern medicine, public health, epidemiology, psychiatry, social assistance will be part of a multiplicity of forms and sources of authority and expertise, and regimes of truth and practice that do not exactly have the State as the point of origin or destination, but that are related to the emergence of the government structure and practices linked to it.

Instead of seeing liberalism from the 18th century onwards as a coherent theoretical set or a consolidated political-institutional structure, governmentality thinkers choose to define it as a way of presenting and rationalizing problems. Liberalism, in this sense, is a practical rationality that is metamorphosed according to the very context in which it deals: against sovereign power and State Reason, against totalitarianism, against the role of the State in guaranteeing fundamental rights, against the collectivization of responsibilities. In this sense, it is a composite of activities not always strictly linked to the State or politics - understood here in its classic conception -, which will both manufacture specific technologies of government and interests, choices and desires of individuals and groups and connect these technologies to the new subjective domains that are being formed.

Take, for example, freedom. For this governmental thought, freedom is not an anthropological constant or a universal value, even if affirmed by liberal thinkers as a principle, but a relationship between governors and the governed. Freedom ends up being a necessity for the exercise of government, which is obliged to produce, consume, organize and manage it. Liberalism is not so much an imperative for freedom as it is a mode of production and a desire for freedom.

Thus, the liberal government becomes a permanent game between the need to regulate this freedom, and the pursuit to establish limits for these interventions. It is in this apparent paradox that it flourishes: against a state that supposedly governs too much, the liberal government continually reviews and creates forms of government of the state itself and in other fields of knowledge and power that modify and restructure state and non-state power practices.

Both biopolitics and the liberal government represent the invention and configuration of a wide and heterogeneous spectrum of technologies, calculations and strategies to manage the economic life, health and habits of the population, civility of the masses and so on. It is in the exercise of the act of governing that the limits of what is or is not state, what is or is not political, what is public or private, what is linked to the responsibility of the individual or the collective are defined and updated.

Liberal government is, in a sense, the possibility of realizing and at the same time contesting biopolitical strategies. To say this implies affirming that liberalism involves the set of political practices that also produced what we understand today as the “bio”, the “psycho” and the “social”, the “individual” and “freedom”, and also the “economy”, the “market” and the “State”. This does not mean to say that social problems are born with liberalism, but that a series of problematizations about the social question (poverty, crime, hunger, decisions about family, work, urban and sanitary conditions, etc.) will be addressed by the liberal government, based on the historical emergence of specific institutions and fields of knowledge and power.

Liberalism will build the very notion of “society” as a complex domain and permeated by antagonistic interests, around individual, family, community and national ties. Social cohesion coexists with rupture and conflict and it will be necessary to develop abstract norms and normality to manage individuals in a regulated and calculated way.

Here homo economicus, a rational subject who bases his choices on economic interests, is central to forging the individual and the very notion of civil society. Central issues for Public Health emerge from this: medical and educational norms within the family, the development of statistics on diseases, censuses on poverty, crime, suicides, alcohol use, etc. (DEAN, 1994DEAN, M. “A Social Structure of Many Souls”: Moral Regulation, Government, and Self-Formation. The Canadian Journal of Sociology, v. 19, n. 2, p. 145-168, 1994.; DONZELOT, 2012DONZELOT, J. A Polícia das Famílias. Rio de Janeiro: Paz e Terra, 2012.)

This liberal government economy not only manufactures the ways of governing, but also the knowledge about those who will be governed. Epidemiologists, health workers, administrators, psychologists, and other specialists will identify who reproduces irresponsibly, who is negligent in relation to their own hygiene, which homes are inadequate, which children are at greater risk of school difficulties, who will have a greater intrinsic chance of become a criminal, and so on.

This myriad of practices was not organized and developed in a coherent way or planned in a unified way but formed a “common vocabulary” around values ​​such as health (and normality), education, safety, risk control and subjectivity. It is this common vocabulary that will shape a series of political aspirations and historical experiences that sought to increase rights and popular participation, reduce inequality and improve indicators of social development.

Although commonly seen as a defender of a generic principle of freedom, the liberal government requires the proliferation and generalization of surveillance and control procedures over individuals themselves, in the name of guaranteeing that same freedom. The expansion of sovereignty and nation-states - concomitant with the very emergence of liberalism - will spread and proliferate the existence of both disciplinary institutions, such as the hospital, the factory, the asylum, the prison, etc., and the security technologies of the population, such as sexuality, epidemiology, economic planning, etc. In this sense, norm and normality play a fundamental role in the proliferation of government practices, in addition to sovereign law, and the expansion of this “biopolitical” domain depends on these government practices.

In other words, the political individual of liberalism shows itself in this paradoxical duality: as a citizen endowed with rights and freedoms and as a normalized subject. It is represented as a rational agent of interests, but dependent on an adequate government, which makes it exercise its choices and freedom in an appropriate way, producing a normalization that will be essential for the neoliberal government of health.

(Re)readings of neoliberal government

More than a form of capitalism or the state, neoliberalism has been described by many scholars as a rationality of government that modifies and disseminates all our social practices (BROWN, 2015BROWN, W. Undoing the Demos: Neoliberalism’s Stealth Revolution. New York: Zone Books, 2015.; DARDOT; LAVAL, 2016DARDOT, P.; LAVAL, C. A nova razão do mundo: ensaio sobre a sociedade neoliberal. 1a ed. São Paulo: Boitempo, 2016.; DEAN, 2014DEAN, M. Rethinking neoliberalism. Journal of Sociology, v. 50, n. 2, p. 150-163, 1 jun. 2014.) , profoundly modifying the way we think and organize the health field. Such reflections make use of Foucault's work around the emergence of neoliberal thinking (FOUCAULT, 2008bFOUCAULT, M. Nascimento da biopolítica. Curso dado no Collège de France (1977-1978). São Paulo: Martins Fontes , 2008b.) and resort to the concept of governmentality to think about this fold between the government of others with that of oneself and the production of subjectivity. In other words, the way in which neoliberalism shapes our relationships with ourselves as workers, consumers, members of a family, with sexual orientations and options, and other diverse identities.

The French philosopher starts from the understanding of the capital-labor theory present in Marx's work, to unfold it in relation to the North American theory of human capital. It carries out a significant discursive mutation: no longer abstract labor and working-class labor as a dialectical opposition to the historical reality of capital, but qualification of the human capital of labor itself and capital increase.

This metamorphosis opens up space for workers to see themselves as entrepreneurs of themselves: for the first time, the worker is not present in the economic analysis as an object - of supply and demand for workforce - but as an “active economic subject” (DEAN, 2017b, p. 30DEAN, M. The Secret Life of Neoliberal Subjectivity. In: SCHRAM, S. F.; PAVLOVSKAYA, M. (Eds.). Rethinking Neoliberalism: Resisting the Disciplinary Regime. 1. ed. New York: Routledge, 2017b.) . Genetic composition, behavior, choices in relation to raising children, their education, family structure, each of these factors and decisions influence the future income of individuals-companies.

Politically positioned on the left, these authors use Foucault's thoughts precisely to broaden the spectrum of analysis of how capital permeates the production of subjectivity. They seek to break with the conception of neoliberalism as an updated and ideological phase of capitalism and use the thought of the French author to criticize the effects of neoliberalism on living conditions and on the subjectivity of workers and most of the population (BROWN, 2015BROWN, W. Undoing the Demos: Neoliberalism’s Stealth Revolution. New York: Zone Books, 2015.; DARDOT; LAVAL, 2016DARDOT, P.; LAVAL, C. A nova razão do mundo: ensaio sobre a sociedade neoliberal. 1a ed. São Paulo: Boitempo, 2016.).

The French author is showing us, in an embryonic way, the subtle differences between sophisticated theories that gave rise to a new rationality of government from the 20th century in two specific contexts, namely, German ordoliberalism and the neo-liberalism of the Chicago School. Thus, he begins its reflections, calling attention to the plurality of recent forms of neoliberalism, its national borders and its particular temporal contexts. This brings neoliberalism to the analysis as something identifiable and studyable, more plural, contingent and historically rooted than a general narrative of global neoliberalism (DEAN, 2019DEAN, M. Rogue Neoliberalism, Liturgical Power, and the Search for a Left Governmentality. South Atlantic Quarterly, v. 118, n. 2, p. 325-342, 1 abr. 2019.) .

As the author himself puts it, neoliberalism “is not Adam Smith; neo-liberalism is not market society; neo-liberalism is not the Gulag on the insidious scale of capitalism”(FOUCAULT, 2008b, p. 131FOUCAULT, M. Nascimento da biopolítica. Curso dado no Collège de France (1977-1978). São Paulo: Martins Fontes , 2008b.). In this sense, neoliberalism appears not as a continuation of liberalism or capitalism at a more developed stage, but above all a critical and updated metamorphosis of liberal forms of government.

More than a naturally constitutive freedom for individuals, typical of liberal thought since the 17th century, its theorists seek to build active forms of freedom. Market assumes a central function, not only as a spontaneous result of the relationships of free individuals but as something that must be permanently legitimized and manufactured. Its logic of effectiveness and maximum increase in gains authority and scientific truth and must guide all government practices in society.

So, neoliberalism does not oppose or empty the State, but takes possession of it to continuously produce a true way of governing it. While classical liberalism sought to limit the influence of the state on a natural market, neoliberalism seeks to find the state's own legitimacy in the market.

In this sense, neoliberalism enshrines and manufactures a specific form of State, a set of values, principles and practices that modify the exercise of political sovereignty, modify the boundaries between public and private and permanently manufacture new material and immaterial flows between capitals, subjectivities, and sociability.

In the name of the diminution of sovereign power, discipline and domination, there is a shift from government to the individual subject and his choices, permanently transforming the environment in which actions are developed and cultivating desirable attributes around competition, virtuosity, wealth, health, body, etc. The original project of neoliberalism was not so much to discipline subjects, but to cultivate desirable attributes of company and competition, acting on the environment of individuals and their field of choice.

The logic of the neoliberal government becomes economic in a triple sense - the corporate economic model is, at the same time, “model, object and project” (BROWN, 2015, p. 62BROWN, W. Undoing the Demos: Neoliberalism’s Stealth Revolution. New York: Zone Books, 2015.) . In other words, the economy organizes the State's organization model, its central object and its expansion plan in relation to other social domains. Economic freedom and the market, seen as naturally regulated elements in classical liberal thought, are no longer intrinsic in nature and must be constantly updated and modified.

In this metamorphosis, the centrality of exchange gives way to stimulating competition between capitals, which represents an important analytical mutation: the natural market between equal to the virtuous and unequal dispute; and the State must foster and guarantee this competition. In the same sense, the logic of entrepreneurship replaces that of production. As we have already stated, an active economic subject emerges - an entrepreneur of “himself” -, governed by a permanent assessment of productivity and quality. Society is no longer a constellation of goods and workers, but of individual and collective companies in relationship.

With the dynamics of the company invading other fields of life, the market also expands its field of truthfulness and validation and becomes the basis of the real regimes of any social experience. To decide whether or not to have a child, judge a criminal, formulate an intervention project on the health of a community, format a school curriculum, organize the transplant queue, prioritize policies for vulnerable groups, decide to provide an ICU bed for an elderly person or a child: all decisions need to be guided by the logic of losses and gains, economic costs, investment and productivity and permanent assessment of quality and satisfaction in relation to results.

This generalization of the company-form in society produces a type of neoliberal health, the result of the permanent work of surveillance and control over the indicators of the body, the mind, risk factors and behaviors, that is, a “business rationalization” of desire and subjectivity (SAFATLE; JUNIOR; DUNKER, 2021, p. 31SAFATLE, V.; JUNIOR, N. S.; DUNKER, C. Neoliberalismo como gestão do sofrimento psíquico. 1. Ed . [s.l.] Autêntica, 2021.) . This permanent creation of new ideals of normality and health - inspired by management techniques of companies, with control of concentration, focus, emotional intelligence and increased productivity and performance - produces new biological, health and psychological truths. Opposing this normality, this updated definition of health, ends up becoming synonymous with failure, weakness and pathological deviation.

The body, the health-disease process, the understanding of normality, risk and the production of subjectivity: governmental thinking will precisely observe how a rationality of corporate governance influences and modifies all aspects of human life and power relations, including our practices in the health field.

As we have discussed previously, one of the central elements for the neoliberal health government is risk. Taking care of yourself ends up being synonymous with seeking behavior that avoids risk and that enables self-control, self-knowledge and self-improvement. And, in the end, an eternal self-surveillance. Furthermore, the privatization and individualization of risks paves the way for the dismantling of universal policies and calls into question the very notion of social citizenship, producing "economic" citizenship as a condition and as an ideal of health, restricted to successful entrepreneurs from themselves.

At this point, the calculation of risk does not appear only as an instrument linked to epidemiological studies but interwoven with the subjectivity of society. Any social experience is defined as individual behavior, choice and conduct; that can be quantified, measured and analyzed as a risk factor. It is up to health experts (not only in clinical care, but also engineers, systems analysts, social scientists, etc.) and, increasingly, to patients themselves to measure these physical and psychological behaviors and characteristics to reveal diseases, disorders and medical conditions that we have and, ultimately, who we really are.

This shift from health to the scope of individual autonomy produces not only the lack of responsibility of the public authorities in relation to the health of individuals and the population, but also an understanding of subjective and “biopsychosocial” normality as equivalent to moral and behavioral choices in relation to us themselves and our “lifestyles”. As a result, obese people who do not lose weight, hypertension and diabetics unable to control blood pressure and blood glucose, heart attackers who continue to smoke, users of alcohol and other drugs that are not abstinent, etc. their lives and choices are treated as unacceptable, and seen as an economic and moral burden for society (ANDRADE; CARVALHO; OLIVEIRA, 2019CARVALHO, S. R.; ANDRADE, H. S. DE; OLIVEIRA, C. F. DE. O governo das condutas e os riscos do risco na saúde. Interface - Comunicação, Saúde, Educação, v. 23, e190208, 2019.).

Instead of intervening on social conditions related to health, such as access to basic income, food, drinking water and shelter, neoliberalism transforms health as a synonym for a lifestyle based on individual choices. Healthy citizens are compared to “good” citizens; sick are considered irresponsible (PETERSEN; LUPTON, 2000PETERSEN, A. R.; LUPTON, D. The new public health: health and self in the age of risk. London: Sage, 2000.).

The governmental perspective suspends old dualities (“subjective-objective”, “structure-consciousness”, “body-mind”, “biological-social”, “freedom-coercion”) and understands that health is intertwined with power practices and regimes of truth. In other words, not only as a reflection of sovereign / state and disciplinary / institutional power, but also as the production of subjects who are morally and economically responsible and whose choices must be permanently evaluated and validated by the true rationality of the market and the company.

It is necessary, however, to recognize that in the movement of these power relations, there is a permanent process of resistance to the forms of subjectivity, normality and risk that we are impelled to desire and choose. We will never be unified and coherent subjects of any governmental regime; thinking about care in neoliberalism requires precisely recognizing it interspersed with regimes of truth and power in dispute, in which health and subjectivity are produced and resist to our government practices. And also, to denaturalize the forms of "responsible", "safe" and "healthy" life that were invented for us, especially in a serious and growing process of unaccountability, insecurity and social inequality to which we are all subjected.

It is also worth noting how the covid-19 pandemic has demanded epidemiological public health practices that did not emerge from the neoliberal government, nor do they respond to its logic. The control of the pandemic has revealed tensions between these institutions that, as we have been discussing, are linked to the history of capitalism and the liberal government of the State, and the neoliberal dream of individual and behavioral risk calculation, incompatible with any minimally successful government program.

This research topic, in our evaluation, gains even more relevance in a global context of progressive reduction of public services and of the advance of a certain skepticism of the State, described as an empty and non-functional space. Such a view is shared even by groups considered “progressive” but with a strong “State phobia” (ANDRADE, 2020 ANDRADE, H. S. DE. State Phobia in Foucault readings. Physis: Revista de Saúde Coletiva, v. 30, n. 4, p. e300421, 2020.; DEAN; VILLADSEN, 2016DEAN, M.; VILLADSEN, K. State phobia and civil society: the political legacy of Michel Foucault. Stanford, California: Stanford University Press, 2016.), that is, critics of the expansion of social rights across the State.

We understand that the methodological use of governmentality can help us carry out more sophisticated analyses of politics, by temporarily suspending a functional and totalizing understanding of the State and making its government rationalities intelligible.We recognize, however, that this immanent view of governmental devices can make centralization of power disappear in a determined territory and by a set of institutions, preventing contemporary analyzes of the exercise of law, sovereignty and different political practices. Ultimately, the very definition of the State as a form of political innovation would end up being suppressed and politics transformed only into a virtual game between various technical rationalities.

Neoliberalism did not really diminish the absolute size of the State or suppress its existence, but it gradually appropriated it and a set of different social institutions, subordinating them to business and the economic logic. In addition, it has been extremely adept at mobilizing antipolitical and antisocial feelings, normalizing and naturalizing inequality and empowering far-right and fascist groups (BROWN, 2018BROWN, W. Neoliberalism’s Frankenstein: Authoritarian Freedom in Twenty-First Century “Democracies”. Critical Times, v. 1, n. 1, p. 60-79, 1 abr. 2018.), bringing them, as in the recent case of Brazil, to power. To face it, it will be necessary to renounce certain anti-state and anti-institutional attitudes present in Foucault's readings and rethink our defense of the meaning of the public and the state in our society.

It will also be necessary to update, dispute and produce new meanings and practices for health, care, risk, normality, subjectivity and freedom. In the words of Wendy Brown, it seems to us fundamental to transform, for example, freedom "from" (as a formal condition) into freedom "from" (as a practice): "to make our dreams come true, and not just survive"; "freedom to choose, not simply to abort or to sleep with - which is important - but also to build lives, build communities and worlds in which we all want to live. ”A freedom that is linked not only to solidarity and well-being social, but also the ability to live in a sustainable and protected environment and be able to “seduce” more than neoliberal freedom, asserting itself as “something with which life is built” (BROWN, 2020BROWN, W. E agora, que o neoliberalismo está em ruínas?, 22 dez. 2020. Disponível em: <Disponível em: https://outraspalavras.net/mercadovsdemocracia/e-agora-que-o-neoliberalismo-esta-emruinas />. Acesso em: 10 fev. 2021
https://outraspalavras.net/mercadovsdemo...
).

Other governmentalities, new biopolitics

As we have discussed, the present article sought to present contemporary readings of neoliberalism that are different from those currently used in Brazilian Public Health, without neglecting the importance of criticism of the economic and political effects of the neoliberal government of the State in recent decades.

Recognizing the multiple expressions of the neoliberal government requires us to think critically not only about its effects on public policies, the role of the State and social rights, but about the social relations surrounding health, normality and illness and about care itself. Government devices, techniques and practices that produce specific and variable forms of subjects to think, calculate, stratify and organize the specific relationships that we establish with ourselves.

In this sense, even without a unique and normative definition, we believe it is necessary to look at the different expressions of neoliberalism, with their heterogeneities and specific contexts around the world. Thinking critically about the neoliberal government will require us to look again at what is “under our nose ...”(DEAN, 2017a, p. 7DEAN, M. Neo-liberalism and our demons. European Political Science, v. 16, n. 2, p. 263-289, jun. 2017a.), that is, to examine both the achievements and the limits of the institutions that we now associate with the so-called liberal democracies, but also the memory of the demands for democracy, socialism, popular sovereignty and the expansion of social rights that marked the last century and the current resistance of movements and contemporary struggles. And to observe how this neoliberal reason has changed our relationships and practices in the health field, changing the reality of risk, disease and normality. In the midst of a neoliberal subjectivity in permanent update and subtly forged by increasingly fluid, algorithmic and sophisticated government networks, the game around health institutions and practices not legislated by the truth of the market remains open.

One of the lessons that governmental thinking teaches us is that, above all, we share the condition of subjects of government. We are all, to some extent, governors and governed. Based on this assumption, we are invited to identify and develop other governmentalities and new biopolitics - less exclusive, normative, and unequal than those that we have unfortunately naturalized and practiced. 22H. S. de Andrade, S. R. Carvalho e C. F. de Oliveira were responsible for preparing the argument, writing and final review of the text.

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  • 2
    H. S. de Andrade, S. R. Carvalho e C. F. de Oliveira were responsible for preparing the argument, writing and final review of the text.

Publication Dates

  • Publication in this collection
    20 Apr 2022
  • Date of issue
    2022

History

  • Received
    12 Mar 2021
  • Reviewed
    21 Mar 2021
  • Accepted
    03 June 2021
IMS-UERJ RJ - Brazil
E-mail: publicacoes@ims.uerj.br